<%@ page contentType="text/html;charset=UTF-8" %>
<%@ include file="/WEB-INF/views/include/taglib.jsp"%>

<div class="panel-body">
    <div >
        <form:form id="inputForm" data-parsley-validate="" modelAttribute="bloodApply" onsubmit="return formSaveLoadDiv('applyListDiv','inputForm','${ctx}/blood/bloodApply/save','${ctx}/blood/bloodApply/list?patientId=${bloodApply.patientId}&visitId=${bloodApply.visitId}',closeApplyFormDiv);" method="post" class="form-horizontal">
            <form:hidden path="id"/>
            <form:hidden path="clinicId" />
            <form:hidden path="patientId" />
            <form:hidden path="visitId" />
            <form:hidden path="inoroutFlag"  value="1"/>
            <form:hidden path="chargeFlag" value="0"/>
            <form:hidden path="applyStatus" value="0"/>
            <div class="form-group">
                <label class="col-lg-2 control-label">血型：</label>
                <div class="col-lg-2">
                    <form:select path="patBloodGroup" id="patBloodGroup"  class="form-control" data-parsley-required="true">
                        <form:options items="${fns:getDictList('BLOOD_TYPE_DICT')}" itemLabel="label" itemValue="value" htmlEscape="false" data-parsley-required="true"/>
                    </form:select>
                </div>
                <label class="col-lg-1 control-label">预输血型：</label>
                <div class="col-lg-2">
                    <form:select path="preBloodType" id="preBloodType"  class="form-control" data-parsley-required="true">
                        <form:options items="${fns:getDictList('BLOOD_TYPE_DICT')}" itemLabel="label" itemValue="value" htmlEscape="false" data-parsley-required="true"/>
                    </form:select>
                </div>
                    <label class="col-lg-1 control-label">血源：</label>
                    <div class="col-lg-2">
                        <form:select path="bloodInuse" id="bloodInuse"  class="form-control" data-parsley-required="true">
                            <form:options items="${fns:getDictList('BLOOD_FROM_TYPE')}" itemLabel="label" itemValue="value" htmlEscape="false" data-parsley-required="true"/>
                        </form:select>
                    </div>
            </div>
            <div class="form-group">
                <label class="col-lg-2 control-label">受血者属地：</label>
                <div class="col-sm-4">
                    <form:select path="patientColony" id="patientColony"  class="form-control" data-parsley-required="true">
                        <form:options items="${fns:getDictList('PATIENT_COLONY')}" itemLabel="label" itemValue="value" htmlEscape="false" data-parsley-required="true"/>
                    </form:select>
                </div>
                    <label class="col-lg-2 control-label">继往输血史：</label>
                    <div class="col-sm-4">
                        <form:select path="useBloodHistory" id="useBloodHistory"  class="form-control" data-parsley-required="true">
                            <form:option value="" label=""></form:option>
                        <form:options items="${fns:getDictList('USE_BLOOD_HISTORY')}" itemLabel="label" itemValue="value" htmlEscape="false" data-parsley-required="true"/>
                    </form:select>
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-lg-2 control-label">诊断及适应症：</label>
                    <div class="col-sm-4">
                        <form:input path="bloodDiagnose" htmlEscape="false" class="form-control"  maxlength="80" />
                    </div>
                    <label class="col-lg-2 control-label">反应及禁忌症：</label>
                    <div class="col-sm-4">
                        <form:input path="bloodTaboo" htmlEscape="false" class="form-control"  maxlength="40" />
                    </div>
                </div>
            <div class="form-group">
                <label class="col-lg-2 control-label">Rh(D)：</label>
                <div class="col-sm-4">
                    <form:select path="rh" id="rh"  class="form-control" data-parsley-required="true">
                        <form:options items="${fns:getDictList('rh_dict')}" itemLabel="label" itemValue="value" htmlEscape="false" data-parsley-required="true"/>
                    </form:select>
                </div>
                    <label class="col-lg-2 control-label">血红蛋白：</label>
                    <div class="col-sm-4">
                        <div class="input-group mb2">
                            <form:input path="hematin" htmlEscape="false" class="form-control"/><span class="input-group-btn"><button class="btn btn-default" type="button">g/L</button></span>
                        </div>
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-lg-2 control-label">白血球：</label>
                    <div class="col-sm-4">
                        <div class="input-group mb2">
                            <form:input path="leucocyte" htmlEscape="false" class="form-control"/><span class="input-group-btn"><button class="btn btn-default" type="button">10^9/L</button></span>
                        </div>
                    </div>
                    <label class="col-lg-2 control-label">血小板：</label>
                    <div class="col-sm-4">
                        <div class="input-group mb2">
                            <form:input path="platelet" htmlEscape="false" class="form-control"/><span class="input-group-btn"><button class="btn btn-default" type="button">10^9/L</button></span>
                        </div>
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-lg-2 control-label">谷丙转氨酶：</label>
                    <div class="col-sm-4">
                        <div class="input-group mb2">
                            <form:input path="alanineAminoTransFeRaSe" htmlEscape="false" class="form-control"/>
                            <span class="input-group-btn">
                                <button class="btn btn-default" type="button">U/L
                                </button>
                            </span>
                        </div>
                    </div>
                    <label class="col-lg-2 control-label">红细胞压积：</label>
                    <div class="col-sm-4">
                        <div class="input-group mb2">
                            <form:input path="heMaToCRit" htmlEscape="false" class="form-control"/>
                            <span class="input-group-btn">
                                <button class="btn btn-default" type="button">L/L
                                </button>
                            </span>
                        </div>
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-lg-2 control-label">丙型肝炎抗体：</label>
                    <div class="col-sm-4">
                        <form:select path="AntibodyToHepatitisC" id="AntibodyToHepatitisC"  class="form-control" data-parsley-required="true">
                        <form:options items="${fns:getDictList('rh_dict')}" itemLabel="label" itemValue="value" htmlEscape="false" data-parsley-required="true"/>
                        </form:select>
                    </div>
                    <label class="col-lg-2 control-label">乙型肝炎表面抗原：</label>
                    <div class="col-sm-4">
                        <form:select path="hbsAntigen" id="hbsAntigen"  class="form-control" data-parsley-required="true">
                        <form:options items="${fns:getDictList('rh_dict')}" itemLabel="label" itemValue="value" htmlEscape="false" data-parsley-required="true"/>
                        </form:select>
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-lg-2 control-label">人类免疫缺陷病毒：</label>
                    <div class="col-sm-4">
                        <form:select path="hiv" id="hiv"  class="form-control" data-parsley-required="true">
                        <form:options items="${fns:getDictList('rh_dict')}" itemLabel="label" itemValue="value" htmlEscape="false" data-parsley-required="true"/>
                        </form:select>
                    </div>
                    <label class="col-lg-2 control-label">梅毒：</label>
                    <div class="col-sm-4">
                        <form:select path="syphilis" id="syphilis"  class="form-control" data-parsley-required="true">
                        <form:options items="${fns:getDictList('rh_dict')}" itemLabel="label" itemValue="value" htmlEscape="false" data-parsley-required="true"/>
                        </form:select>
                    </div>
                </div>
                <div class="form-group">
                <label class="col-lg-2 control-label">输血目的：</label>
                <div class="col-sm-4">
                    <form:select path="useBloodAim" id="useBloodAim"  class="form-control">
                        <form:option value="" label=""></form:option>
                        <form:options items="${fns:getDictList('USE_BLOOD_AIM')}" itemLabel="label" itemValue="value" htmlEscape="false" data-parsley-required="true"/>
                    </form:select>
                </div>
                    <label class="col-lg-2 control-label">申请时间：</label>
                    <div class="col-sm-4">
                        <input name="createDate" readonly class="form-control"  value="<fmt:formatDate value="${bloodApply.createDate}" pattern="yyyy-MM-dd HH:mm:ss"/>" />
                    </div>
                </div>
                <div class="form-group">
                    <div class="col-sm-offset-2 col-lg-10">
                        <input id="btnSubmit" class="btn btn-primary" type="submit" value="保 存">&nbsp;
                        <input id="btm" class="btn btn-default" type="button" onclick="closeApplyFormDiv()" value="关 闭">&nbsp;
                </div>
            </div>
        </form:form>

        </div>
    </div>